Basic Information
| Provider Information | |||||||||
| NPI: | 1982639969 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANCISCAN MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | FMG-FRANCISCAN SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535727120 | ||||||||
| FaxNumber: | 2535721071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535727120 | ||||||||
| FaxNumber: | 2535721071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | FIELD | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2538589192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRANCISCAN MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD00046199 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7140064 | 05 | WA | MEDICAID |